455002792-11-14-2025-59-AS-LCRR-DNMPA8-20251121100816

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 455002792
Report Date: 11/14/2025
Date Signed: 11/14/2025 04:22:35 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/22/2025 and conducted by Evaluator Kayla Adkison

PUBLIC

COMPLAINT CONTROL NUMBER: 59-AS-20250522152444

FACILITY NAME:	DIAMOND RESIDENTIAL		FACILITY NUMBER:	455002792
ADMINISTRATOR:	LEAK, RANDY		FACILITY TYPE:	735
ADDRESS:	16981 CATALINA WAY		TELEPHONE:	(530) 200-0701
CITY:	REDDING	STATE: CA	ZIP CODE:	96003
CAPACITY:	4	CENSUS: 3	DATE:	11/14/2025
		UNANNOUNCED	TIME BEGAN:	11:15 AM
MET WITH:	Lejean Tenner, Care Staff		TIME COMPLETED:	12:30 PM

ALLEGATION(S):

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Staff did not follow physicians’ orders.
Staff did not ensure resident's catheter care is performed by a skilled professional.
Staff do not ensure facility has adequate PPE supplies.
Staff do not keep facility records updated.
Staff do not answer phone.
Staff do not provide food in the quantity necessary to meet residents' needs.

INVESTIGATION FINDINGS:

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On November 14, 2025, Licensing Program Analysts (LPA) Kayla Adkison and Marisa Chiarelli arrived at the facility unannounced for the purpose of delivering complaint findings. LPA met with Care Staff, Lejean Tenner, and explained the purpose of the visit. There were 1 (one) staff, and 2 (two) clients present during the visit.

During the course of the investigation, several documents were collected, interviews were conducted, and observations were made

Report continued on LIC 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Kayla Adkison
LICENSING EVALUATOR SIGNATURE:	DATE: 11/14/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 4

Control Number 59-AS-20250522152444

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: DIAMOND RESIDENTIAL	FACILITY NUMBER: 455002792
	VISIT DATE: 11/14/2025

NARRATIVE

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Allegation: Staff did not follow physicians’ orders.

It was alleged that C1 was diagnosed with an infectious bacterium which would require a 10-day round of antibiotics and C1 would need to be quarantined to protect other clients in care. The staff member (S1) who took the resident to the doctor returned to the facility and informed facility staff that the client was now required to remain in their room until they could be seen again by a doctor and retested for the presence of the bacteria.

After reviewing C1’s medical records from the hospital and primary care physician, LPA found no documentation that C1 was directed to remain in quarantine, nor that C1 was diagnosed with any potentially hazardous bacterium. Four (4) of four (4) staff interviewed were all in agreement that they had no knowledge of the reasoning for C1 needing to be quarantined as no medical documentation was ever provided. LPA received a written letter from an additional staff member indicating the same information.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Allegation: Staff did not ensure resident's catheter care is performed by a skilled professional.

It was alleged that staff are unable to properly care for a resident’s necessary catheter. As a result of interviews conducted, it was discovered that C1 is primarily responsible for the care of their own catheter/bag. C1 is able to independently empty the bag once it is full and staff are trained on how to disinfect the bag when it is being changed from the day to night bag and vice versa. C1 has monthly appointments with their urologist for catheter line changes and irrigation.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Continued on LIC 9099C

SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Kayla Adkison
LICENSING EVALUATOR SIGNATURE:	DATE: 11/14/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2025

LIC9099 (FAS) - (06/04)

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Control Number 59-AS-20250522152444

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: DIAMOND RESIDENTIAL	FACILITY NUMBER: 455002792
	VISIT DATE: 11/14/2025

NARRATIVE

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Allegation: Staff do not ensure facility has adequate PPE supplies.
It was alleged that while a resident was reportedly required to be quarantined for an potentially infectious disease, that staff did not provide Personal Protective Equipment (PPE) for staff and client use. It was further alleged that on May 19, 2025, a representative from Far Northern Regional Center conducted an “infectious disease protocol inspection” at the facility, which, the facility allegedly failed for lack of PPE.
During the investigation, staff interviews were conducted, of which, (3) three of (3) staff interviewed denied this to be the case. All staff interviewed stated there had never been a time when the facility was without the necessary PPE to do their job safely and effectively.

On May 29, 2025, and June 12, 2025, during visits to the facility, LPA Adkison observed a plethora of PPE supplies available to staff located in the facilities med room. On October 31, 2025, and November 12, 2025, LPA attempted to contact the Far Northern Regional Center caseworker named in the complaint, however, was unsuccessful.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Allegation: Staff do not keep facility records updated.
It was alleged that staff failed to keep updated records of residents currently residing at the facility. On May 29, 2025, LPA reviewed client files and found them to be in compliance and current. Additionally, on June 12, 2025, during the facility’s annual inspection, all client fields were again reviewed and found to be current and in compliance with Title 22 regulations.
Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Allegation: Staff do not answer phone.
It was alleged that staff do not answer the facility phone when residents have called for assistance when they are away from the facility. Specifically, it was alleged that on May 15, 2025, a client fell out in the community while on their own. The client used their personal cell phone in an attempt to contact staff at the facility; however, the call was not answered. During interviews conducted with staff, two (2) of two (2) staff interviewed noted that there had been a power outage that same day. Additionally, (1) one staff noted that there had been an incident when the facility phone had been accidentally placed in a cabinet and it had taken staff a couple days to find it.

Continued on LIC 9099C

SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Kayla Adkison
LICENSING EVALUATOR SIGNATURE:	DATE: 11/14/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2025

LIC9099 (FAS) - (06/04)

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Control Number 59-AS-20250522152444

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: DIAMOND RESIDENTIAL	FACILITY NUMBER: 455002792
	VISIT DATE: 11/14/2025

NARRATIVE

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Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Allegation: Staff do not provide food in the quantity necessary to meet residents' needs.

It was alleged that staff are not providing large enough meals to meet the needs of clients in care. One (1) of four (4) staff (S1) stated that the facility is regularly low on food. S1 further stated that it is impossible for the staff to follow the planned menu as the items that are on the menu are not in stock in the facility. All additional staff stated that the facility has never been in danger of running out of food.

On May 29, 2025, LPA observed plenty of food in the facility for the number of clients in care. Additionally, on June 16, 2025, and July 24, 2025, LPA Sarah Benson observed food in a adequate amount for the number of clients in care.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED.

No deficiencies are being cited as a result of this investigation. Exit Interview conducted. A copy of the report was provided, via email, to administrator, Crystal Monismith.

SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Kayla Adkison
LICENSING EVALUATOR SIGNATURE:	DATE: 11/14/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2025

LIC9099 (FAS) - (06/04)

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